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For all muniuyal buslress license questions, contact: Oty of South Bend • Department of Community Imrestment <br />227 West Jefferson Blvd • Sude 14005 •South Bend, Indiana 46601 • 574.235.5912 • F' 574.235.9021 <br />LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT <br />MUNICIPAL CODE SECTION - 4-35 <br />III. OWNERSHIP (Continued) <br />3. corporation (Continued) <br />Name #3: <br />Title: <br />Business Address: <br />City: State: Zip: <br />Residential Address: <br />City: State: Zip: <br />IV. PERSONAL DATA <br />A. Applicant's Legal N <br />B. Residential Addres <br />City Osceola state:IN zip:46661 <br />C. Residential Telephone Number: 574-888-3888 <br />D. Residential Fax Number. <br />E. Cellphone Number: 574-888-3888 <br />F. E-Mail Address: Jingwang0329Qgmail.com <br />G. Position with business: Owner <br />H. Please list all criminal convictions (If any), excluding trafficviolations: <br />Nature of Conviction City State Date <br />(Attach additional sheets If necessary) <br />I. Please list all addresses for three (3) years prior to application date: <br />Street Address City State Dates <br />